8.3 Reproductive Health, Family Planning & Gynaecological Conditions
Key Takeaways
Implants and IUDs have typical-use failure rates below 1%, compared with about 7% for the pill and 13% for male condoms.
Condoms are the only contraceptive method that also protects against STIs and HIV, so dual protection is recommended.
Emergency contraception options are levonorgestrel within 72 hours, ulipristal within 120 hours, or a copper IUD within 5 days.
A threatened miscarriage has a closed cervical os, while an inevitable miscarriage has an open os.
Ruptured ectopic pregnancy presents with sudden one-sided pain, shoulder-tip pain and shock, and is a surgical emergency.
Reproductive Health, Family Planning and Gynaecological Conditions
The CARICOM Blueprint's health-problem tables include problems of the childbearing years (20–44): abortion, ectopic pregnancy, pelvic inflammatory disease (PID), fibroids, ovarian cysts and tumours, uterine and breast cancers, and sexually transmitted infections. Family planning is also core primary health care. This section covers what an entry-level RN needs for clinics, gynaecology wards and the emergency room.
Family Planning: Choosing a Method
Good counselling covers:
- effectiveness;
- how the method is used;
- side-effects;
- return to fertility;
- protection against STIs; and
- the client's preferences.
The client decides. The nurse makes sure the choice is informed and voluntary.
| Method | Typical-use pregnancy rate in the first year* | Key nursing points |
|---|---|---|
| Implant (etonogestrel) | about 0.1% | Lasts 3 years; irregular bleeding is common |
| Levonorgestrel IUD | 0.1–0.4% | Lasts several years; lighter periods |
| Copper IUD | about 0.8% | Up to 10 years; heavier periods; also emergency contraception |
| Female sterilisation | about 0.5% | Permanent; needs informed consent |
| Vasectomy | about 0.15% | Not effective at once: use another method until semen analysis confirms no sperm |
| Injectable (DMPA, every 3 months) | about 4% | Return to fertility may be delayed by several months; irregular bleeding, weight gain |
| Combined pill, patch, ring; progestogen-only pill | about 7% | Daily or regular use needed; check medical eligibility |
| Male condom | about 13% | The only methods that also protect against STIs and HIV are condoms ("dual protection") |
| Withdrawal, fertility awareness | up to about 20% or more | Depends heavily on correct use |
*Approximate typical-use failure rates from the CDC's contraceptive effectiveness summary.
Medical Eligibility
WHO's Medical Eligibility Criteria (MEC) rate each method from category 1 (no restriction) to category 4 (unacceptable health risk). Combined (oestrogen-containing) methods are category 4 for:
- women aged 35 or older who smoke heavily;
- blood pressure of 160/100 mmHg or above;
- a history of deep vein thrombosis or pulmonary embolism;
- migraine with aura;
- current breast cancer; and
- the early postpartum weeks while breastfeeding.
Progestogen-only methods and IUDs are usually safe alternatives.
Emergency Contraception
- Levonorgestrel 1.5 mg: as soon as possible, ideally within 72 hours.
- Ulipristal acetate: within 120 hours (5 days).
- Copper IUD: inserted within 5 days; this is the most effective option.
Emergency contraception is not an abortion method. Offer STI testing and follow-up, and screen for coercion or abuse.
Early Pregnancy Complications
Miscarriage (Spontaneous Abortion)
| Type | Bleeding and pain | Cervical os | Products of conception |
|---|---|---|---|
| Threatened | Light bleeding, mild cramps | Closed | Pregnancy may continue |
| Inevitable | Heavier bleeding, cramps | Open | Loss cannot be prevented |
| Incomplete | Heavy bleeding | Open | Some tissue retained; evacuation needed |
| Complete | Bleeding settling | Closed | All passed |
| Missed | Little or none | Closed | Non-viable pregnancy retained |
| Septic | Fever, foul discharge, tenderness | Varies | Infection: antibiotics, evacuation, watch for sepsis |
Nursing care:
- monitor bleeding by pad count and vital signs;
- keep products of conception for examination;
- give anti-D immunoglobulin to Rh-negative women as prescribed; and
- provide emotional support, because grief after miscarriage is real.
Ectopic Pregnancy
Implantation outside the uterine cavity, usually in a fallopian tube. Risk factors include:
- previous PID or chlamydia;
- a previous ectopic pregnancy;
- tubal surgery;
- pregnancy with an IUD in place; and
- smoking.
Classic picture: a missed period, one-sided lower abdominal pain and light vaginal bleeding.
Rupture causes sudden severe pain, shoulder-tip pain (blood irritating the diaphragm), dizziness and hypovolaemic shock. This is a surgical emergency:
- two large-bore IV cannulas;
- cross-match blood;
- keep the client nil by mouth;
- monitor vital signs; and
- prepare for theatre.
An unruptured, early ectopic pregnancy may be treated with methotrexate under strict criteria.
Gynaecological Conditions
- Uterine fibroids (leiomyomas): benign smooth-muscle tumours, more common and earlier in women of African descent. They cause heavy menstrual bleeding with iron-deficiency anaemia, pelvic pressure and urinary frequency. Treatment ranges from monitoring and iron to myomectomy or hysterectomy.
- Pelvic inflammatory disease: lower abdominal pain, cervical motion tenderness, fever and abnormal discharge. Treat early with antibiotics and treat partners. Complications include infertility, ectopic pregnancy and chronic pelvic pain.
- Ovarian cyst torsion or rupture: sudden severe one-sided pain, often with vomiting. This is an emergency.
- Menopause: periods stop permanently, on average around age 51. Hot flushes, sleep problems and vaginal dryness are common, and osteoporosis and cardiovascular risk rise afterwards. Teach weight-bearing exercise, calcium and vitamin D, and discuss options for symptom relief. Postmenopausal bleeding always needs investigation.
Screening and Self-Awareness
- Cervical screening: WHO (2021) recommends HPV DNA testing as the primary test from age 30 in the general population, repeated every 5–10 years. Women living with HIV start earlier (25) and are screened more often. Pap smears and VIA are still used where HPV testing is not yet available. Follow the national programme.
- Breast awareness: know what is normal for you and report lumps, skin dimpling, nipple changes or discharge promptly. Clinical breast examination and mammography follow the national guidelines.
- HPV vaccination in early adolescence prevents most cervical cancers (Section 3.1).
Sexual and Reproductive Rights and Safety
- Take a sexual history privately and without judgement. Ask about partners, condom use, symptoms and coercion.
- Intimate partner violence: look for injuries inconsistent with the history, delayed care-seeking, or a partner who will not leave the client alone. Ask privately, document objectively, give safety information and refer.
- For adolescents, protect confidentiality within the law and institutional policy. A suspected sexual offence against a child triggers the mandatory reporting duties in Section 2.2.
- Abortion is regulated by national law, which varies across CARICOM. Nurses give non-judgemental post-abortion care to any woman who presents with complications, whatever the circumstances.
A 24-year-old client who is 7 weeks pregnant presents with sudden severe left lower abdominal pain, pain at the tip of the shoulder, pallor, pulse 124 and BP 84/52. What should the nurse anticipate?
Oral antibiotics for pelvic inflammatory disease and partner notification
Discharge home with analgesia and a repeat ultrasound next week
Bed rest and pad counts for a threatened miscarriage, with review in the morning
Emergency preparation for ruptured ectopic: IV access, cross-match, theatre
A 38-year-old woman who smokes 20 cigarettes a day and has migraine with aura asks to start the combined oral contraceptive pill. What is the nurse's best response?
Explain combined methods are unsafe for her and offer progestogen-only or IUD options
Start the combined pill and recheck her blood pressure in a year
Advise her to use withdrawal instead, since it carries no hormonal risk at all
Tell her she cannot use any contraception until she stops smoking completely
Which finding indicates a threatened, rather than an inevitable, miscarriage?
An open cervical os with strong, regular cramps
Heavy bleeding with tissue passing through the cervix
A closed os with light bleeding and a viable pregnancy
Fever and foul-smelling discharge
A client had a vasectomy last week and asks when he and his partner can stop using other contraception. What should the nurse tell him?
After semen analysis confirms no sperm, about 3 months later
Immediately, because the tubes are already cut and tied
As soon as there is no more pain or swelling at the site
After one week of rest
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